Mentor Intake Form
Your experience can make a difference. Tell us a little about yourself and how you hope to inspire, encourage, and support the next generation.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Communication
*
Phone
Email
Text
Current Occupation / Job Title
Company / Organization
Highest Level of Education Completed
Please Select
High School
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate
Professional Certification
Other
What are your strengths and weaknesses?
Mentoring Experience and Preferences
Have you mentored before?
*
Yes
No
If yes, briefly describe your mentoring experience
What age group(s) are you most comfortable mentoring?
*
Ages 12–14
Ages 15–17
Other
Which areas do you feel most confident supporting?
*
Academic support
Career exploration
College preparation
Life skills
Goal setting
Emotional encouragement
Other
How often are you available to mentor?
*
Weekly
Biweekly
Monthly
Occasionally
Other
Preferred meeting format
*
In person
Virtual
Either
How many teens are you comfortable mentoring?
*
1
2
3
4 or more
How would you describe your mentoring style?
*
Supportive
Goal-oriented
Hands-on
Encouraging
Flexible
Other
What values are most important to you as a mentor?
*
Background Screening and Motivation
Are you willing to complete a background check?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If yes, please explain
Why do you believe mentorship is important for teens?
*
Why are you interested in becoming a mentor with Teens with Dreams Inc.?
*
References
Reference 1 Name
*
Reference 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 1 Email
*
example@example.com
Reference 1 Relationship
*
Reference 2 Name
*
Reference 2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2 Email
*
example@example.com
Reference 2 Relationship
*
Agreement and Emergency Contact
Mentor Name (Agreement)
*
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Emergency Contact Relationship
*
Submit
Submit
Should be Empty: